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planimetry measures intraluminal
pressures and the cross sectional area
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swallow demonstrating a‘ bird’ s beak’ appearance with a dilated oesoph- |
Box 4. Types of achalasia |
adequately controlled using anti-reflux medications
14, 22
.
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more common in patients over 50. 15
Management options include medi-
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of the lumen in real time, thus assessing the distensibility of the lumen as it responds to an applied pressure. The device is inserted transorally but requires deep sedation or general anaesthesia and is limited to a handful of Australian centres. 6
Figure 3 outlines a proposed approach to the initial investigation and management of dysphagia.
COMMON GASTROENTERO- LOGICAL CAUSES OF DYSPHAGIA
Motility disorders
ACHALASIA
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agus that tapers sharply distally( see figures 4 and 5), as well as poor oesophageal emptying with incomplete relaxation of the LOS. Similarly, endoscopy typically features a dilated food or fluid-filled oesophagus and a tight gastro-oesophageal junction. The main role of endoscopy in this setting is to exclude pseudoachalasia, which presents similarly but is caused by mechanical obstruction— for example, from a malignancy. 6, 21
Management strategies for achalasia target symptom minimisation and avoidance of nutritional deficits. 22 Advise patients to eat slowly with
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• Type I( classic)— minimal contractility / peristalsis in oesophageal body.
• Type II( compression)— absent contractility with intermittent periods of panoesophageal pressurisation.
• Type III( spastic)— premature / spastic distal oesophageal contractions with no peristalsis.
those with comorbidities that prevent surgical intervention should oesophageal rupture occur. 1, 23
The most invasive, but also the most efficacious, treatment for acha-
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OESOPHAGEAL HYPOMOTILITY Hypomotility of the oesophagus is frequently encountered, especially in association with reflux disease, and it is more frequently seen in the elderly. 24 Despite the prevalence of oesophageal hypomotility, it tends to cause dysphagia only when the condition is severe. It is therefore prudent to seek further proof before attributing the dysphagia to hypomotility.
Although systemic sclerosis is the best-described connective tissue disorder that results in hypomotility of the oesophagus, other connec-
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cal treatments with nitrates and calcium-channel blockers, botulinum toxin injection into the oesophageal body, or surgical myotomy / POEM targeting the spastic segments of the
15, 26 oesophagus.
GASTRO-OESOPHAGEAL REFLUX DISEASE GORD can result in dysphagia because of either the development of reflux oesophagitis and its associated inflammation or the formation of a benign oesophageal stricture causing luminal narrowing. 6, 12 Risk factors for GORD include increased abdominal pressure from obesity, pregnancy
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ACHALASIA is characterised by
impaired relaxation of the LOS and defective or absent oesophageal body peristalsis. 21 It is said to have a prevalence of one in 10,000 in the general population; however,
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adequate fluid intake during meals. Dietary modification may be required with the guidance of a dietitian.
Medical management generally has poor efficacy. 23 Agents used include calcium-channel block-
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lasia is myotomy to the LOS; this can be performed either surgically, usually via laparoscopy, or increasingly endoscopically via per-oral endoscopic myotomy( POEM). 14 A laparoscopic Heller myotomy gen- |
tive tissue diseases may also result in hypomotility but are less well described in the literature. 25 There is no effective treatment for oesophageal hypomotility, and management is centred mainly around dietary |
and a weak LOS— often as a result of a hiatus hernia. 12 If the diagnosis is uncertain, ambulatory pH monitoring can be performed to assess the extent of acid reflux. 27 Indications for referral for anti-reflux surgery include |
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the prevalence is higher in places |
ers and nitrates. Endoscopic injec- |
erally also involves a partial fundo- |
modification. |
symptoms of oesophagitis refrac- |
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where there is greater awareness of |
tion of botulinum toxin into the LOS |
plication, and apart from providing |
tory to PPI therapy or a need / desire to |
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the condition and greater availability of motility testing. 15 The condition occurs equally in males and females, |
can reduce LOS tone by blocking the release of acetylcholine at the neuromuscular junction and can provide |
durable improvement to dysphagia in more than 90 % of patients, it also has the benefit of reducing |
HYPERCONTRACTILE DISORDERS OF THE OESOPHAGUS Three distinct hypercontractile con- |
cease the PPI. 27 Benign oesophageal strictures are predominantly caused by GORD. |
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and although it typically presents |
short-term( generally 3-6 months) |
However, they can also result from |
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between the ages of 20 and 50, the diagnosis is not infrequently made in other age groups. 21
The pathophysiology relates to degeneration of motor nerves in the myenteric plexus, leading to the loss of inhibitory neurotransmission, unopposed excitation of the LOS and loss of normal peristaltic activity. 6 The aetiology is unknown but is sus-
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symptom relief in up to 80 % of patients, but it needs to be repeated regularly. 6, 13, 23 This is considered firstline therapy in frail patients who are unsuitable for more invasive interventions or when diagnostic uncertainty prevents the performance of
15, 23 more definitive treatments. Pneumatic balloon dilation to rupture the LOS has efficacy in up
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The aetiology of achalasia is suspected to be immune mediated with a potential viral trigger.
reflux complications after myotomy
because of the fundoplication. 14 POEM is performed via endoscopy
ditions are recognised in the Chicago Classification for the diagnosis of oesophageal motility disorders. These
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other causes of scarring, including pill-induced ulceration— for example, from oral bisphosphonates or potassium supplements. 12 Therapeutic dilatation can be performed at the time of endoscopy to reduce dysphagia. 15 Patients may require repeated treatment that can safely be performed at intervals of 1-2 weeks. 14 |
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pected to be immune mediated with a potential viral trigger. 6, 15 Box 4 lists the types of achalasia. |
to 90 % of patients, and benefit can last several years, although more than one treatment is often required |
and is less invasive than surgical myotomy.
Greater experience with this
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include spastic( type III) achalasia, hypercontractile oesophagus and distal oesophageal spasm. 18 |
EOSINOPHILIC OESOPHAGITIS Eosinophilic oesophagitis is an allergic condition where eosinophilic infil- |
The clinical presentation is predominantly with dysphagia to both solids and liquids, but patients may also present with difficulty belching, regurgitation, chest pain, weight loss |
to maintain medium- to long-term response. 23 The efficacy and rate of complications are operator dependent, so this procedure is ideally performed in high-volume centres. The |
technique has resulted in good efficacy similar to a surgical myotomy, at least in the medium term. 14 The lack of a concurrent fundoplication results in post-procedure reflux |
The term‘ jackhammer oesophagus’ is sometimes used to describe severe repetitive spastic contractions seen on manometry, while‘ corkscrew oesophagus’( see figure 6) is an endo- |
tration of the oesophageal mucosa leads to stiffening and fibrosis, with formation of strictures and potential impaired peristalsis. 15 It is most common in younger males and is associ- |
or food bolus obstruction. 6 The classical investigation findings in achalasia include a barium |
risk of perforation is roughly 1-3 %, with bleeding in 2 %. 14 Pneumatic balloon dilation is contraindicated in |
rates as high as 40 %, with significant reflux oesophagitis of around 10 %. 14 Reflux can generally be |
scopic and radiological description. 15 The conditions typically result in dysphagia and chest pain. 6 They are |
ated with a history of atopy or food allergy. 6, 28
Patients often present for the
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